Neonatal resuscitation

Dr pramod sarwa

What is neonatal resuscitation?

series of actions which are used to assist newborn babies who have difficulty with making the physiological ‘transition’ between the womb and ‘the outside world’.

Techniques Advocated and Used to Resuscitate Newborns 1850–1950

Squeezing the chest (Prochownich method) Raising and lowering the arms while an assistant compressed the chest (Sylvester method) Rhythmic traction of the tongue (Laborde method) Tickling the chest, mouth, or throatDilating the rectum by a raven’s beak or a corn cobImmersion in cold water, sometimes alternating with immersion in hot water Yelling, Shaking , Rubbing, Slapping, and PinchingNebulisation of brandy mist Insufflation of tobacco smoke into the rectum

History of Neonatal Resuscitation

Assited respiration has been accepted as the mainstay of neonatal resuscitation for about the last 40. Formal teaching programmes have evolved over the last 20 years. The last 10 years have seen international collaboration, which has resulted in careful evaluation of the available evidence and publication of recommendations for clinical practice.

The International Liaison Committee on Resuscitation (ILCOR, 1992)

Formed in 1992 to provide a forum for liaison between resuscitation organisations in the world AHA,europeian ,aust.ILCOR 1997 made recommendations for Basic Life support for the newly born. It noted that:

"the paucity of pediatric and newborn clinical resuscitation outcome data makes scientific justification of recommendations difficult". Discussion of advanced life support for newborns was considered beyond the scope of the document.”

ILCOR 2000-2010

ILCOR 2000 Guidelines- Identified controversial neonatal resuscitation issues.

The Neonatal Subcommittee of ILCOR reconvenes approximately every five years to evaluate available evidence that may support a change in the recommendations.

ILCOR 2005,2010 Guidelines -The literature was researched and a consensus was reached on those issues.

Poor intrapartum fetal oxygenation

Also referred as asphyxiaCommon cause of death & long term disability (mental & neurological)Estimated to contribute to 9% of all < 5 mortalityBurden of disease assessment – 42 million disability-adjusted life years (DALYs)

What is ASPHYXIA?

Asphyxia is a disturbed physiological state due to deprivation of oxygen supply to the fetus / newborn.

Oxygen compromise may be– Acute or chronic– Mild or severe– Once off or repeated

episodes

When and why does asphyxia occur?

Asphyxia may occur

– Antenatally

– During labour / perinatal

– After delivery• Resuscitation not

expedient

Causes of asphyxia are many (direct / indirect)! Eg.– MOTHER

• Pre-eclampsia• Obstructed labour• Hypotension

– PLACENTA/CORD• Cord prolapse• Antepartum haemorrhage

– BABY• IUGR• Postmature• Malpresentation/breech

Solutions to reduce deaths & disabilityThere are 3 possible intervention points.– PRIMARY INTERVENTION – prevention of asphyxia

• Maternal health and reproductive health• Health facility birth • Risk factor identification (intrapartum)• Early obstetric intervention

– Recognise and manage complications

– SECONDARY INTERVENTION – NEONATAL RESUSCITATION– TERTIARY PREVENTION

• Care of neonatal encephalopathy - NICU (referral services)

The Global Need for neonatal Resuscitation, FIGO, Wall et al

What does it involve?1. Preparation at every birth

2. Assessment of the baby’s condition at birth

3. Interventions1. Dry / stimulate2. Clear airway3. Support breathing

• Ventilate (bag/mask)• ?oxygen

4. (Advanced support)• Chest compressions• Intubation / ventilation• Medications

4. Ongoing assessment

BASIC

Which babies need resuscitation?

Assess: Gestation – term or preterm?Breathing or Crying?Good tone?If NO then act quickly

–The first “golden minute”

Newborn resuscitation Assessment

Airway, Breathing and Circulation

all assessed before and during resuscitation:

Tone, Breathing, Heart Rate and Oxygenation

Newborn resuscitationBasic approach

Maintain normothermia

Newborn life support algorithm

Assessment and airway

Breathing

Circulation

Supplementary Oxygen/Air

There are concerns about potential adverse effects of 100% oxygen on breathing physiology, cerebral circulation, and potential tissue damage from oxygen free radicals.There is growing evidence that air is as effective as 100% oxygen for the resuscitation of most infants at birth, and is associated with less mortality and no evidence of harm.

Treatment Recommendation Once adequate ventilation is established with lung inflation/ventilation , if the heart rate remains low, the priority should be to support cardiac output with chest compressions and coordinated ventilations.Supplementary oxygen should be considered for babies with persistent central cyanosis.

Tracheal Suctioning

A RCT showed that tracheal intubation and suctioning of meconium-stained but vigorous infants at birth offers no benefit and accordingly is no longer indicated No studies in Meconium-stained, depressed infants. These should receive tracheal suctioning immediately after birth and before stimulation, presuming the equipment and expertise is available.

Initial BreathsThe optimum pressure, inflation time, and flow required to establish an effective FRC has not been determined.Average initial peak inflating pressures of 30-40 cm water used successfully to ventilate unresponsive term infants Ventilation rates of 30-60 breaths min−1 commonly used, but the relative efficacy of various rates has not been investigated

Treatment Recommendation Establishing effective ventilation is the primary objective in the management of the apnoeic or bradycardic newborn in the delivery room.Positive-pressure ventilation alone is effective for resuscitating almost all apnoeic or bradycardic newborn infantsPrompt improvement in HR is the primary measure of adequate initial ventilation; chest wall movement should be assessed if heart rate does not improve.

Treatment Recommendation If pressure is being monitored, an initial inflation pressure of 20 cm H2O may be effective, but a pressure ≥30—40 cm H2O may be necessary in some term babies.

If pressure is not being monitored, the minimal inflation required to achieve an increase in heart rate should be used.

There is insufficient evidence to recommend optimal initial or subsequent inflation times.

Ventilation for Preterm Infants

Studies indicate that preterm lungs are more easily injured by large-volume inflations immediately after birthAvoid creation of excessive chest wall movement during ventilation of preterm infants immediately after birth.If positive-pressure ventilation is required, an initial inflation pressure of 20—25 cm H2O is adequate for most preterm infants, consider higher pressure if no prompt improvement in heart rate or no chest movement is obtained.

Treatment RecommendationThere are insufficient data to support or refute the routine use of CPAP during or immediately after resuscitation in the delivery room.In preterm baby-Start resuscitation with CPAP of at least 5–6 cm water via mask or nasal prongs to stabilize the airway and establish functional residual volume. It is not clear at present if delivery room CPAP will reduce the need for subsequent surfactant treatment or mechanical ventilation

Exhaled CO2 Detectors to Confirm Tracheal Tube Placement

A positive test confirms tracheal placement of the tube, whereas a negative test strongly suggests oesophageal intubation.Exhaled CO2 detection is a reliable indicator of tracheal tube placement in infants

Identify oesophageal intubations faster than clinical assessmentsPoor or absent pulmonary blood flow may give false-negative results may lead to unnecessary extubation.

Neonatal Chest Compressions

Asystole or bradycardia less than 60 that is not increasing with airway and ventilationUse thumbs on lower half of sternum (one finger’s width below nipple line)Compress 1/3 AP diameter, 100 times per minuteCompression ventilation ratio is 15.2

Adrenaline-Route and Dose A paediatric study & studies in newborn animals showed no benefit and a trend toward reduced survival rates and worse neurological status after administration of high-dose IV adrenaline during resuscitation. Animal & adult human studies show that when given tracheally, considerably higher doses of adrenaline than currently used are required to show a positive effect.

Adrenaline-Route and Dose Lack of human data. Reasonable to continue to use adrenaline when adequate ventilation and chest compressions have failed to ↑ the HR to >60 beats/min. Use the IV route for adrenaline. The recommended IV dose is 0.01-.03 mg kg−1. Do not give higher doses of intravenous adrenaline. If the tracheal route is used, give a higher dose (0.1 mg kg−1).The safety of these not studied.

Sodium Bicarbonate (SB)Infusion

At birth babies who do not respond to initial resuscitative efforts have acidosisIV SB common practice for over 30 years- no good evidenceOnly 1 high quality study of 55 babies that compared SB treatment with no treatment, did not show any benefit nor any adverse effects. There is insufficient evidence that SB reduces mortality & morbidity in infants receiving resuscitation at birth.

Volume ExpansionCrystalloids and Colloids

Three RCT in neonates showed that isotonic crystalloid is as effective as albumin for the treatment of hypotension In consideration of cost and theoretical risks, an isotonic crystalloid solution rather than albumin should be the fluid of choice for volume expansion in neonatal resuscitation.

Maintenance of Body Temperature

Studies showed an association between hypothermia and increased mortality in premature newborns.Premature infants continue to be at risk for hypothermia when treated according to current recommendations (dry the infant, remove wet linens, place the infant on a radiant warmer)

Hyperthermia

Babies born to febrile mothers (temp. >38 ◦C) have an increased risk of death, perinatal respiratory depression, neonatal seizures, and cerebral palsyThe goal is to achieve normo-thermia and to avoid iatrogenic hyperthermia in babies who require resuscitation.

GlucoseBoth low and high blood glucose may have adverse effects

Based on available evidence, the optimal range of blood glucose concentration to minimise brain injury following asphyxia and resuscitation cannot be defined.

Infants requiring resuscitation should be monitored and treated to maintain glucose in the normal range.

Induced HypothermiaIn a multicenter trial involving newborns with suspected asphyxia, selective head cooling (34–35°C) was associated with a non-significant reduction in the overall number of survivors with severe disability at 18 months but a significant benefit in the subgroup with moderate encephalopathy.A second large trial of asphyxiated newborns treatment with systemic hypothermia (33.5 °C) following moderate to severe encephalopathy was associated with a significant (18%) decrease in death or moderate disability at 18 months.

Discontinuation of resuscitation

If there is no return of heart rate after 10 minutes, evidence suggests that the newly born is likely to suffer from severe neurological impairment or death.Hence, it is suggested that if there is no return of heart rate after 10 minutes of adequate resuscitation, it is acceptable to discontinue resuscitation.

Summary

Everybody who conducts a delivery must be able to resuscitate Anticipate & planCall for help & work as a teamWe should be prepared at all timesUse all available resourcesLets give our newborn a good start